Ruminations by a non-academic general surgeon from the heart of the rust belt.

Saturday, January 22, 2011

Gawande and O-Mama-Care

Atul Gawande's latest piece in the New Yorker is out this week and I suspect the raves will be soon to follow. President Obama is assuredly frantically scrambling to slide a reference to it in his upcoming State of the Union Address.

The article deals with a possible solution to the conundrum of "high utilizers" in the health care system. By "high utilizers" (HU's) we mean those 1% of patients who, due to a combination of generalized sickness/ non-compliance/poor physician management, account for gargantuan shares of systemic health care costs (sometimes up to a third of all hospital expenses). Gawande investigates why this is the case and hangs out with a couple of idealistic physicians who may have stumbled upon a potential fix.

Unsurprisingly, HU's tend to come from lower socioeconomic classes. The diabetic who doesn't have health insurance and only rarely seeks medical attention for severe complications of his diabetes in an ER is obviously going to accumulate more societal costs for his disease over the course of a lifetime compared with the compliant diabetic with decent health coverage who sees a doctor every six months for preventative therapy. So Gawande discovered a couple of altruistic visionaries who decided to create entire medical practices devoted to the care and management of these HU's. Sounds pretty cool so far, right? Focus on the non-compliant patients without insurance who plow through health resources like my buddy Starhay does sliced cheddar at a fantasy football draft and you may be able to lower overall expenditures.

But here's where Gawande's paragons of medical philanthropy start to lose me. The practices he follows around (one in Camden, NJ and the other in Atlantic City) aren't just garden variety charity clinics for unhealthy, uninsured patients. These practices are High-Intensity, Life-Management Centers for the downtrodden and woebegone. Multidisciplinarian teams of doctors, nurses and social workers attack these HU's like it's the first day of July two a days for a team coming off an 0-10 football season. Patients are assigned "health coaches" who schedule appointments, make sure patient X has a ride to office, double check that patient X has filled prescriptions, double checks that pills are actually being taken on a daily basis, arrange exercise time, suggest dietary changes, encourage religious worship (?!?!), make follow up house calls, fill out paperwork for disability/public aid, provide psychologists for mental health issues, enroll in Yoga classes, improve housing conditions, and provide hour long full body massages once a week. (OK, I made the last one up). There's even a passage detailing how one health coach was able to reduce 911 calls and ER visits. Initially, the patients were told to simply program the clinic number into their cell phone speed dials. But too many didn't know how to do this. So the coaches did it for them. Voila. Reduced 911 calls.

I mean seriously? Aren't we talking about grown adults here? Apparently there are professionals who think that taking someone's cell phone and programming a number into his speed dial because he can't figure out how to do it himself, or even just write the damn clinic number down on a piece of paper taped to his refrigerator is some sort of triumph in social re-engineering? This isn't a solution to the health care crisis. It a thinly veiled play for bureaucratized, state-sponsored citizen dependency.

I mean, I'm all for social safety nets and making sure a bare minimum of health care is universally available to all. But this is crazy. Whatever happened to personal responsibility? Why is it "inhumane" to expect an adult human being to take care of himself? People talk about the encroachment of the "nanny state" with health care reform--- but this is a Mommy State plan. Besides, how many people are going to want government-subsidized social workers and psychologists crawling up their ass every minute of every day, asking if they ate their vegetables for dinner.

To be clear, I am impressed by the results achieved by the doctors cited in the article. Their selfless toil and humanistic approach to health care is admirable. But we have to expect a little more from our citizenry. There are many ways we can be better. Foremost involves acting like a freaking responsible adult.

So what do you do with the (hopefully) small fraction of "adults" who continuously abrogate their "adult" responsibilities for self care? The current non-solution of forcing them to seek ER and hospital care has resulted in the explosion of costs ultimately borne by the rest of us. At least this approach makes an effort to actually address the problem.

Your concerns about mission-creep, complete with hyperbolic references to the Nanny state, are also unwarranted. Most people I know who are on Welfare want nothing more than to get off of it. If any of those sorry souls ever decided to begin acting like adults, both they and the clinics involved would be thrilled at the chance for discharge back into the real world.

Dino-Come on man, these people who abrogate (great word!) their adult responsibilities need to be expected to do at least some things on their own! When the doctor wants to see you in three weeks for a blood sugar follow up, guess what, that means you have to get your ass to the clinic. The solution is not to create a giant sprawling multidisciplinarian bureaucracy that hounds and monitors these people's wayward lives. Those mornings when I dont feel like running, it would be nice if some federal social worker rapped on my bedroom door and showed me pictures of what I would look like in ten years if I cease all exercise. But I am able to surmount my laziness somehow someway. Seriously, Dino. These people had to have someone program a phone number into their cell phones.

Plus, there's a disturbing passage in the article that I didn't even get into about a third party analyst that pores over the medical records of a company's employee roster looking for the HU's who contribute to rising premiums. It's illegal for a company to do something like that on its own for obvious reasons. But Gawande seems to think that making a centralized database of everyone's medical records available to third party assessors motivated to cut costs and increase revenue could never be abused in nefarious ways.

The whole piece just struck me as being a little naive and faintly totalitarian.

To be entirely honest, I think that you are being a bit naive, not the other way around. If there's one thing I've seen in my internship, it's that not that many people feel a genuine sense of personal responsibility. No matter what we do in society to motivate people to work harder and take pride in themselves, there will always be a certain percentage of people who either cannot or will not take care of themselves despite the ability to do so. I don't know that we're morally obligated within society to help these people out when they don't want to help themselves, but I think there is a reasonable financial incentive to "O-Mama-Care" these people into reducing our bottom line in the long run. If it means signing them up for exercise classes (ps, don't mock yoga as extraneous, it's pretty damn tough while low impact for the fragile pt) , I'm all for it.

Okay, so you don't believe in social work or out reach nursing. And you can program your own cell phone. Got that. Not surprised as you are among the most advantaged, coddled class of people God ever put on the Earth. AND I'll bet you've never been without health insurance a SINGLE day of your life, or coped with a SINGLE chronic disease (so glad you can run every day, congrats on your good fortune and health..lucky you!) NEWSFLASH: Not everyone has your brains, your good health, your rich resources. Many however, have a much better developed ability to IMAGINE themselves in different circumstances. We all have deficits. That, dear Buckeye Surgeon, is yours.

Anon-Never did I say I "didn't believe in outreach nursing or social work". And believe it or not I actually didn't attend Exeter as a youth. Public schools. Broken home. Welfare for a couple years growing up. I have plenty of "imagination".

I have all the respect in the world for these docs who put these programs together. But it isn't a long term viable solution (how are you going to incentivize enough doctors to participate in these worst of the worst practices across the country?). Rather it breeds the sort of dependency that will only perpetuate the problems we're trying to eradicate.

PS, there are plenty of people I come across every day who live and thrive with chroinic diseases. The starting QB for a team in the NFC title game today is a type I diabetic (Jay Cutler).

I don't have a problem at all in helping those who participate in helping themselves get better. I want to make that link secure. I don't think too many of us have a problem with facilitating access to those without the means to gain access if a partnership is made.

I think the conversation needs to steer back to what to do with those who refuse to participate in getting better and maintaining a functioning level of health, when, that level and the means of getting there is obtainable/has been offered to them.

I am not one to coddle an adult. I have a real accurate bullshit radar. We all know that EMTALA is the best and worst of things. I think we need to really look at how to limit the damage from those who ruin it for everybody else. Who knows, I could need it someday. Heck, I know many, many nurses who cannot find employment in this country. Many more who have positions that now do not provide insurance - forced part time. Could be me next.

So - do you demand that your surgical patients heal themselves without assistance? Are you one of those people who believe people with depression should just snap out of it? I'm all for personal responsibility - I also know you don't get people to be personally responsible by telling them to be personally responsible if they have lost the ability to be personally responsible, or maybe never had it in the first place.

Like any life skill personal responsibility is a learned behavior. Some of us are fortunate enough to learn it early. And some people don't know how to program numbers into their phones. We can stand around and roll our eyes and mock them for sport - or we can provide them an opportunity to learn, or at least allow others to provide that opportunity if you don't support it yourself. It's an experiment. It might work. It might not. But, it's showing some interesting early results. What if it works?

I'm enjoying reading your archives and I had two cents to contribute here, courtesy of a M.S. in Experimental Psych (with lots of behaviorism) and a nasty, cynical attitude that kept me away from the clinical Ph.D. programs.

What matters isn't what people should or shouldn't do. It's what they will do. It's how to get them to do what we want them to do. And the "we" in that sentence is scary, because it can represent whoever's interests are at stake in the conversation. I would very much like it if society's interests came first, before those of corporations and rich people.

But regardless of who "we" are--whether we're Big Brother or the citizenry--talking about what people should do is useless. People know what they should do. They simply aren't motivated to do it. And how do you want to motivate people with chronic illnesses that they aren't managing? Seriously, excluding the methods used by these health care providers, how do you think we can possibly get people who already, demonstrably, don't care that their actions will lead to the deterioration of their health, to care?

Or do we let them sicken and die? Because that's not motivation. That's punishment for being stupid, or depressed, or ignorant, or even just lazy. And it seems a bit inhumane. It's excessive. Humans are very much stimulus-response organisms, whether we like it or not, and we can either ignore that and pretend that free will trumps all, or we can acknowledge it and use it for our own purposes. Advertisers are already doing it. Why not people who want to make us better, instead of worse?

The biggest question is always this: what do we want from this situation? Do we want to pay less for health care for these people? Or do we want to punish them?

We've spent pretty much all of human history punishing each other for all sorts of things. It's rarely worked out well for us, especially people who aren't in positions of privilege. It takes time and energy to set aside natural and basic feelings of resentment and annoyance and see things through a pragmatic, analytical lens, but it is the only way we're going to accomplish anything. Otherwise we're just reiterating the last 5,000 years of bloody imperialism and god-kings, interpersonal squabbles about different values that lead to centuries of boring conflict. We have science. We can do better than that, and we should.

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